Cirugía de rescate en las recidivas locales del carcinoma de nasofaringe

Introduction and objectives

Chemoradiotherapy is the treatment of choice for nasopharyngeal carcinoma. Local recurrences are one of the leading causes of death in these patients, and surgical salvage the treatment of choice. Our goal was to evaluate and compare the results of salvage surgery in the treatment of local recurrence of nasopharyngeal carcinomas comparing endoscopic to open approaches.

Tratamiento de los tumores laríngeos localmente avanzados mediante microcirugía transoral láser

In recent years, surgical treatment of laryngeal cancer has evolved towards transoral resections. Transoral laser microsurgery (TLM) combines microscopic control with the precise cutting and coagulation capability that laser equipment has, making it possible to remove laryngeal tumours by the transoral approach, with very good oncological and functional outcomes. In early tumours, local control with TLM has been proved to be as good as in open surgery and totally comparable to that achieved under radiation protocols, at a much lower cost. Consequently, TLM is presently considered a first line treatment in early laryngeal cancer.These good oncological and functional results have led to an increase in TLM indications for intermediate or advanced carcinomas. In this article we review the role of TLM in the treatment of locally advanced tumours of the larynx, with special emphasis on appropriate patient selection and different technical considerations.Although TLM is not presently considered a standard treatment for locally advanced laryngeal tumours, the outcomes published in the literature are very encouraging, with results comparable to other treatment alternatives in appropriately selected patients. Compared to external surgical procedures, TLM reduces patient morbidity, provides faster recovery and makes it possible to avoid tracheotomy in a high number of patients.     

Valor de las pruebas de control postural dinámico de la posturografía en ancianos con vestibulopatía

Introduction and objectivesThe stability limits and rhythmic weight shift tests study the functional capacity to achieve voluntary postural control of movement in the standing position. The objectives of this paper are to know the interest of these tests in the evaluation of elderly people with vestibular disorders and their relation with the number of falls suffered during the year prior to the study.Material and methodsSixty elderly people (65-80 years old) with vestibular disorders (patients) and 60 healthy subjects (control group) of similar age were selected. According to videonystagmographic and clinical criteria, the patients group was divided into compensated and decompensated. All the subjects in the sample performed the stability limits and rhythmic weight shift tests with the NedSVE/IBV system. The number of falls of each subject was determined by a meticulous anamnesis.ResultsCompensated patients, decompensated patients and the control group had similar scores in this instrumental functional evaluation, without any statistically significant differences. None of the parameters assessed in this study correlated statistically with the subjects’ number of falls during the year prior to the study.ConclusionsThe stability limits and rhythmic weight shift tests are of little utility in the functional evaluation of the elderly with vestibular disorders and in the detection of patients with greater risk of falls.     

Utilidad de los colgajos e injertos endonasales en cirugía endoscópica nasosinusal y de base de cráneo. Documento de consenso

IntroductionSkull base reconstruction is one of the greatest challenges extended endonasal endoscopic surgery. Many grafts and flaps from the endonasal fossa have been demonstrated to be useful in the control of complications such a cerebrospinal fluid leaks. Review and analysis of these resources are necessary in skull base recontruction to improve outcomes.ObjectivesThe target is to create a consensus document on the use of different endonasal flaps and grafts in the skull base surgery.Material and methodsLiterature review of the most relevant free grafts and vascularized flaps from the endonasal fossa. Analysis using the Delphi method on the use of the different endonasal resources for endoscopic repair of skull base defects.ResultsWe obtained two results: 1) A selection of the most representative flaps and grafts from the endonasal fossa, describing origin, surface and indications, based on a literature review. 2) A consensus document, using Delphi methodology, with general considerations (2), recommendations (10) and limitations (6) of the different endonasal flaps and grafts.ConclusionsWe present the first consensus document in the field of extended endonasal endoscopic surgery using the Delphi method as a working tool. We highlight the usefulness of the nasoseptal flap together with other endonasal flaps and grafts for skull base reconstruction.     

Parálisis facial: guía de práctica clínica de la Sociedad Española de ORL

Bell's palsy is the most common diagnosis associated with facial nerve weakness or paralysis. However, not all patients with facial paresis/paralysis have Bell's palsy. Other common causes include treatment of vestibular schwannoma, head and neck tumours, iatrogenic injuries, Herpes zoster, or trauma. The approach to each of these conditions varies widely. The purpose of this guideline is to provide clinicians with guidance on the treatment and monitoring of patients with different causes of facial paralysis. We intend to draft a practical guideline, focusing on operationalised recommendations deemed to be useful in the daily management of patients. This guideline was promoted by the Spanish Society of Otolaryngology and developed by a group of physicians with an interest in facial nerve disorders, including at least one physician from each Autonomous Community. In a question and answer format, it includes 56 relevant topics related to the facial nerve.     

Manejo de las fístulas nasales de líquido cefalorraquídeo según su tamaño. Nuestra experiencia

ObjectiveWe present our experience in the reconstruction of cerebrospinal fluid (CSF) leaks according to their size and location.Material and methodsFifty-four patients who underwent advanced skull base surgery (large defects) and 62 patients with CSF leaks of different origin (small and medium-sized defects) were included. Large defects were reconstructed with a nasoseptal pedicled flap positioned on fat and fascia lata and lumbar drainage was used. In small and medium-sized leaks of other origin, intrathecal fluorescein 5% was applied previously to identify the defect. Fascia lata in an underlay position was used for reconstruction, which was then covered with mucoperiosteum from the turbinate. Perioperative antibiotics were administered for 5-7 days. Nasal packing was removed after 24-48 hours.ResultsThe most frequent aetiology for small and medium-sized defects was spontaneous (48.4%), followed by trauma (24.2%), iatrogenic (5%) and others. The success rate was of 91% after the first surgery and 98% in large skull base defects and small/medium-sized respectively. After rescue surgery, the rate of closure achieved was 100%. The follow-up was 15.6 ± 12.4 months for large defects and 75.3 ± 51.3 months for small/medium-sized defects without recurrence.ConclusionsEndoscopic surgery for closure of any type of skull base defect is the gold standard approach. Defect size does not play a significant role in the success rate. Fascia lata and mucoperiosteum allow a reconstruction of small/medium-sized defects. For larger skull base defects, a combination of fat, fascia lata and nasoseptal pedicled flaps provide a successful reconstruction.     

Fístula tras laringectomía total. Estudio retrospectivo y revisión bibliográfica

BackgroundThe pharyngocutaneous fistulae is troublesome and the most common complication following total laryngectomy. Our objetive was to determine the incidence of pharingocutaneous fistulae after the total laryngectomy in our serie and to make review of the medical literature.MethodsWe made a retrospective study of a serie of 81 consecutive cases of laryngeal carcinoma treated between 1995 and 2008 in our section. Total laryngectomy was performed in 29 cases and 52 patients treated with organ preservation approach, were excluded. In 14 cases, the procedure was combined with radical neck dissection, pharyngeal resection or myocutanenous flaps. Nasogastric tube for feeding in the postoperative period was used in all patients and surgical gastrostomy was performed in 5 cases.ResultsOur incidence of fistulas when total laryngectomy was the alone procedure is 20 % and 34.5 % when simultaneous surgical proceedings were associated. Spontaneous closure was noted in 80 % of the cases and the mean hospitalization time was 23 days.ConclusionsMost of the fistulas can be managed with conservative treatment. Pectoralis major myocutanenous flap is appropriate when conservative treatment has failed. In small fistulas, nasogastric or gastrostomy tube for feeding can be successfully managed in the ambulatory follow up. The cost-benefit relation must be better analyzed.     

Utilidad diagnóstica de la densidad ósea de la cápsula laberíntica en el diagnóstico de la otosclerosis por tomografía de alta resolución

ObjectiveThe aim of this study is to compare the bone density around the otic capsule in otosclerotic patients with a control group, and find the cut-off values of bone density from which we can diagnose the disease.Material and methodsA retrospective case-control study was performed. Bone densities in Hounsfield units (HU) from 28 otosclerotic ears were compared to the densities of 33 non otosclerotic capsules. These densities were measured in eight regions of interest (ROI) where the otosclerotic foci are usually found. The mean density of these regions (PROMED) was taken. Furthermore, the ROC curves of each ROI and the mean density (PROMED) were calculated.ResultsAll radiological densities in HU of each ROI and the mean density in otosclerotic patients were lower compared to non otosclerotic ears. The area under the ROC curve of each ROI and the mean density showed that the areas with greater accuracy for the diagnosis of otosclerosis were mean density, the fissula ante fenestram, and precochlear region, with cut-off values of 1980 HU, 1750 HU and 2114 HU, respectively.ConclusionThe mean density of the otic capsule (PROMED), the density in the fissula ante fenestram (ROI 1) and in the precochlear region (ROI 3) seem to be the most useful parameters to make a diagnosis of otosclerosis.     

Análisis crítico de la cirugía robótica laríngea

In recent years, transoral robotic surgery (TORS) with the Da Vinci robot has been used for the removal of laryngeal cancers with the objective to improve functional and aesthetic outcomes without worsening survival. The advantages of TORS are described in this article. However, its disadvantages, mainly high cost amongst others, do not make robotic surgery the current treatment of choice for laryngeal tumours; transoral laser surgery is superior in most cases. Major technical improvements are expected. Smaller, more ergonomic, new-generation robots better adapted to the head and neck will probably be available in the near future.     

Reconstrucción de defectos orofaríngeos tras cirugía transoral robótica. Revisión y recomendaciones de la Comisión de Cirugía de Cabeza y Cuello de la Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello

Transoral surgery of the oropharynx has seen an important evolution in recent years, expanding the surgical options available (TORS, TOUSS, TOLS). The capacity to resect increasingly extensive lesions and the number of patients who benefit from them. This fact has led to an evolution in the reconstruction of surgical defects after transoral surgery. This article aims to review the possible reconstructive techniques, indications and factors to be taken into account prior to surgery, proposing a protocol to assess the need for transoral reconstruction based on the depth of the defect, the staging, and previous treatment.     

Utilidad de la gammagrafía con 201tl en el diagnóstico del carcinoma de laringe

For the evaluation of a patient with a laryngeal tumor we need the clinical exam and other exams as the CT scan or MRI. Those studies have a sensitivity of less than 80%. For that reason in the last years there has been a development of new techniques trying to increase the accuracy. The 201Tl SPECT is one of them although it was developed for cardiological purpouses. We present our experience in 46 patients with laryngeal tumor in whom we did a 201Tl SPECT as part of the extension study. The sensitivity of the study was 81.6% in the diagnosis of the primary tumor and 46.1% for the neck adenopathies.The 201Tl SPECT can be a good method for the evaluation and detection of recurrences in patients with pharyngo-laryngeal tumor.     

Rinotilexomanía: manifestación de enfermedades psiquiátricas

ObjectiveTo increase the knowledge of rhinotillexomania, or compulsive nose picking, as a manifestation of psychiatric disease through the presentation of a case series and a review of the literature.MaterialWe present three clinical cases with self-destructive nasal injuries as a symptom of different psychiatric diseases.ResultsOne patient presented amputation of the middle turbinate as a manifestation of an obsessive-compulsive disorder of bipolar disease. Two patients had a septal perforation. In the first patient it was the first symptom of factitious dermatitis and in the second it was during the course of schizophrenia. Only control with psychological treatment and psychotropic drugs stabilised the nasal injury.ConclusionSelf-induced injuries are a diagnostic and treatment challenge for the ENT specialist. A knowledge of psychiatric diseases related to destructive injuries to the nose will improve the approach to patients and prevent the progression of local damage and its complications.     

Síndrome de Ramsay-Hunt causante de parálisis laríngea

The Ramsay-Hunt syndrome is the association of facial palsy and varicella-zoster virus infection with involvement of the ear canal and eardrum. It may be associated with deafness, tinnitus and dizziness. It can sometimes affect the lower cranial nerves. A case of an immunocompetent patient with affectation of the VII, VIII and X cranial nerves is presented.     

Etiología y tratamiento de la parálisis laríngea: estudio retrospectivo de 108 pacientes

ObjectivesTo review the aetiology and treatment of laryngeal paralysis diagnosed at our hospital and to describe the available therapeutic options.MethodsRetrospective review of medical records of 108 patients diagnosed with unilateral and bilateral vocal fold paralysis between 2000 and 2012, identifying the cause of paralysis and its treatment.ResultsOf the 108 cases analysed, 70% had unilateral vocal fold immobility and 30% bilateral immobility. The most frequent aetiology in both cases was trauma (represented mainly by surgical injury), followed by tumours in unilateral paralysis and medical causes in bilateral paralysis. Half of the patients with unilateral paralysis (38) were treated surgically, with medialization thyroplasty. In bilateral vocal fold immobility, the treatment consisted of tracheostomy in patients with threatened airway (40%). We planned to widen the air passage in 9 patients (27%), performing cordectomy in most of them.ConclusionsThe aetiology observed in our patients is similar to that described in the literature. In cases of unilateral vocal fold paralysis, we believe thyroplasty is the procedure of choice. In bilateral paralysis, it is possible to perform cordectomy in selected patients once the airway has been secured.     

Factores implicados en el éxito y fracaso de la dacriocistorrinostomía endoscópica desde nuestra experiencia

IntroductionChronic dacryocystitis is the condition secondary to permanent lacrimonasal duct stenosis (LNDS) that generates epiphora and recurrent conjunctivitis. Endoscopic dacryocystorhinostomy (EDCR) is a more natural route than the external route and offers higher success rates than the laser technique. We value this centre's experience in this procedure.Patients and methodsA retrospective review was carried out in our centre of the medical records of adult patients undergoing EDCR due to LNDS between 1995 and 2019. The minimum follow-up period required after surgery was 6 months.ResultsOver 297 months, 167 EDCR procedures were performed on 156 patients, with an average age of 65.7±11.6 years and a male/female ratio of 1/1.98. The functional improvement was 86%, with an anatomical success rate of 87%. Lack of clinical improvement statistically significantly correlated with the age of the patient and the time since onset of the LNDS, the presence of concomitant systemic (especially diabetes mellitus) or ophthalmological disease, the intraoperative finding of a thickened tear sac and absence of drainage of the tear sac when marsupialised. Longer-term stent carriers in the rhinostomy had poorer outcomes. There were no postoperative complications of interest.ConclusionsEDCR is an effective and safe technique, based on stable anatomical references. Failure rate seems to be multifactorial and should be considered in older, multipathological patients, with a long duration of the condition.     

Autofonía de etiología infrecuente: síndrome de la trompa patulosa

We report the case of a patient with autophony diagnosed with a patulous Eustachian tube. The patient was treated according to the technique described by Bluestone and Cantekin, inserting an indwelling catheter into the tube. Good results were obtained after one year of monitoring.